Swagger: sentinel lymph nodes - PowerPoint Presentation

1. Swagger: sentinel lymph nodes

2. SummarySentinel lymph node practice across SWAGGERPreliminary data: SWAGGER SLN Endometrial cancerBGCS guidelines SLNPORTEC 3

3. SWAGGER SLN endometrial cancer

4.

5. Exeter:SLN for G3 endometrial cancer72 cases – 6 recurrences, 4 deathsCheltenham:No SLNFull pelvic lymphadenectomy G319 cases – 12 had full pelvic lymphadenectomy1/12 (8.3%) positive nodes – chemotherapy. Distant recurrence and died

6. Bristol:40 cases G2 and G39/40 (22.5%) only unilateral SLN mapped31/40 (77.%%) SLN mapped bilaterallyPosition of SLN:External iliac 35Internal iliac 11Common iliac 4Obturator 18Parametrial 314 cases G2 – 1/14 (7%) positive SLN, had chemotherapy26 cases G3 – 1/26 (4%) positive SLN, had chemotherapy

7. Bristol 40 cases SLN G2/3 continued:6 recurrences – 3 local, 3 distant3 deaths

8. BGCS guidelines Sentinel nodes Vulval Cancer:Techniques TC99 with blue dye Not enough evidence for ICGHistological ultra-staging for SLNUnifocal tumours <4cm with no suspicious lymph nodes (clinical or examination) SLN standard of careIf no SLN detected then full lymphadenectomy

9. Cervical cancerTechniques TC99 with blue dye or ICGHistological ultra-staging for SLNSLN algorithms can be considered stage 1a1 with LVSI,Stage 1a2-1b1 (tumours less than 2cm)If no SLN detected then full lymphadenectomy

10. Int J Gynecol Cancer 2017;27: 154Y158)pooled detection rate of 89.2% (95% CI, 86.3Y91.6) pooled sensitivity rate of 90% (95% CI, 88Y92)Tumours<2cm sensitivity 96-100%

11. Endometrial cancer:Cervical injection for SLNTechniques TC99 with blue dye or ICGHistological ultra-staging for SLNCan be considered in high risk endometrial cancer (clear cell, serous, grade 3 endometrioid, carcinosarcoma)If no SLN detected then full lymphadenectomy

12. Lancet Oncol 2017; 18: 384–92. 10 centres in USAAny grade, apparent stage 1 endometrial cancerICG dye used, injected into cervixPAN 58%293/340 (86%) successful mapping177/340 (52%) bilateral mapping SLN

13.

14. ResultsThe sensitivity was 97·2% (95% CI 85·0–100; McNemar’s p=1). False-negative rate 3%Negative predictive value of 99·6% (95% CI 97·9–100). Isolated Para-aortic SLN detected 3/340 (<1%)6 patients (17%) had positive SLN outside conventional lymphadenectomy

15. Lancet Oncol (july) 2019; 20: 1273–85Between 2006-2013 660 women randomisedstage I endometrioid grade 3 cancer with deep myometrial invasion or lymphovascular space invasion, or both; stage II or III disease; orstage I–III disease with serous or clear cell histologyReceive radiotherapy alone (48·6 Gy in 1·8 Gy fractions given on 5 days per week) orChemoradiotherapy (two cycles of cisplatin 50 mg/m² given intravenously during radiotherapy, followed by four cycles of carboplatin AUC5 and paclitaxel 175 mg/m² given intravenously

16.

17. 5-year overall survival was 81·4% (95% CI 77·2–85·8) with chemoradiotherapyversus 76·1% (71·6–80·9) with radiotherapy alone (adjusted hazard ratio [HR] 0·70 [95% CI 0·51–0·97], p=0·034)

18. 5-year failure-free survival was 76·5% (95% CI 71·5–80·7) versus 69·1% (63·8–73·8; HR 0·70 [0·52–0·94],p=0·016).

19. stage III endometrial cancer, 5-year overall survival was 78.5% (95% CI 72.2–85.4)with chemoradiotherapy versus 68.5% (61.2–76.7)with radiotherapy alone (HR 0・63 [95% CI 0.41–0.99]; p=0.043)

20. In women with stage I–II disease,5-year overall survival was 83・8% (95% CI 78・4–89・5) with chemoradiotherapyversus 82・0% (95% CI 76・5–87・7) with radiotherapy alone HR 0・84 [95% CI 0・52–1・38]; p=0・50), 5-year failure-free survival was 81・3% (95% CI 74・7–86・3)with chemoradiotherapy versus 77・3% (95% CI 70・5–82・7) with radiotherapy alone (HR 0・87 [95% CI 0・56–1・36]; p=0・54;

21. 5-year overall survival was 71・4% (95% CI 60・1–84・7) with chemoradiotherapy versus 52・8% (40・6–68・6) with radiotherapy alone (HR 0・48 [95% CI 0・24–0・96]; p=0・037) 5-year failure-free survival was 59・7% (95% CI 45・1–71・6) with chemotherapyversus 47・9% (33・9–60・6) with radiotherapy alone (HR 0・42 [95% CI 0・22–0・80]; p=0・008

22. Results - recurrencesDistant metastases 78 of 330 women (5-year probability 21·4%; 95% CI 17·3–26·3) in the chemoradiotherapy group versus 98 of 330 (5-year probability 29·1%; 24·4–34·3) in the radiotherapy-alone group (HR 0·74 [95% CI 0·55–0·99]; p=0·047).Isolated vaginal recurrence was the first site of recurrence in one patient (0·3%; 95% CI 0·0–2·1) in both groups (HR 0·99[95% CI 0·06–15·90]; p=0·99)isolated pelvic recurrence was the first site of recurrence in three women (0·9%[95% CI 0·3–2·8]) in the chemoradiotherapy group versus four (0·9% [95% CI 0·3–2·8]) in the radiotherapy-alone group (HR 0·75 [95% CI 0·17–3·33]; p=0·71)

23. Result – adverse side effectsAt 5 years, only one grade 4 adverse event (ileus or obstruction) was reported (in the chemoradiotherapy group).grade 3 adverse events did not differ significantly between the two groups, occurring in 16 (8%) of 201 women in the chemoradiotherapy group versus ten (5%) of 187 in the radiotherapy-alone group (p=0·24).grade 3 adverse event was hypertension (in four [2%] women in both groups).grade 2 or worse adverse events were reported in 76 (38%) of 201 women in the chemoradiotherapy group versus 43 (23%) of 187 in the radiotherapy-alone group (p=0·002).Sensory neuropathy persisted more often after chemoradiotherapy than after radiotherapy alone, with 5-year rates of grade 2 or worse neuropathy of 6% (13 of 201 women) versus 0% (0 of 187). No treatment-related deaths were reported.